DNCB reactivity and prognosis in 419 patients with malignant melanoma

Autologous tumor-derived heat-shock protein peptide complex-96 (HSPPC-96) in patients with metastatic melanoma

BACKGROUND

Glycoprotein-96, a non-polymorphic heat-shock protein, associates with intracellular peptides. Autologous tumor-derived heat shock protein-peptide complex 96 (HSPPC-96) can elicit potent tumor-specific T cell responses and protective immunity in animal models. We sought to investigate the feasibility, safety, and antitumor activity of HSPPC-96 vaccines prepared from tumor specimens of patients with metastatic melanoma.

METHODS

Patients with a Karnofsky Performance Status >70% and stage III or stage IV melanoma had to have a metastasis >3 cm in diameter resectable as part of routine clinical management. HSPPC-96 tumor-derived vaccines were prepared in one of three dose levels (2.5, 25, or 100 microg/dose) and administered as an intradermal injection weekly for 4 consecutive weeks. In vivo induction of immunity was evaluated using delayed-type hypersensitivity (DTH) to HSPPC-96, irradiated tumor, and dinitrochlorobenzene (DNCB). The gamma-interferon (IFNgamma) ELISPOT assay was used to measure induction of a peripheral blood mononuclear cell response against autologous tumor cells at baseline and at the beginning of weeks 3, 4, and 8.

RESULTS

Among 36 patients enrolled, 72% had stage IV melanoma and 83% had received prior systemic therapy. The smallest tumor specimen from which HSPPC-96 was prepared weighed 2 g. Twelve patients (including 9 with stage IV and indicator lesions) had a negative DNCB skin test result at baseline. All 36 patients were treated and evaluable for toxicity and response. There were no serious toxicities. There were no observed DTH responses to HSPPC-96 or to autologous tumor cells before or during treatment. The IFNgamma-producing cell count rose modestly in 5 of 26 patients and returned to baseline by week 8, with no discernible association with HSPPC-96 dosing or clinical parameters. There were no objective responses among 16 patients with stage IV disease and indicator lesions. Among 20 patients treated in the adjuvant setting, 11 with stage IV melanoma at baseline had a progression-free and overall survival of 45% and 82%, respectively, with a median follow-up of 10 years.

CONCLUSION

Treatment with autologous tumor-derived HSPPC-96 was feasible and safe at all doses tested. Observed immunological effects and antitumor activity were modest, precluding selection of a biologically active dose. Nevertheless, the 25-microg dose level was shown to be practical for further study.

Successful treatment of in-transit melanoma metastases using topical 2-4 dinitrochlorobenzene

A 78-year-old woman presented with multiple histologically proven in-transit melanoma metastases involving the lower half of the left leg. Initial therapy with liquid nitrogen cryotherapy had some short-lived success but was not tolerated by the patient. As further lesions began to develop, daily topical application of 2% 2-4 dinitrochlorobenzene to the lesions was commenced. During the first 2 years of therapy a partial response was achieved, with treated lesions regressing while new lesions developed. Eventually a long-term remission of almost 2 years with no clinical evidence of cutaneous melanoma deposits was achieved. This treatment did not prevent metastatic lymph node and ultimately fatal liver involvement. Topical immunotherapy can be a useful adjunct in the treatment of cutaneous melanoma metastases, particularly in those patients who are unable to tolerate other destructive modalities of therapy.

Cytokine levels in whole blood cell cultures as parameters of the cellular immunologic activity in patients with malignant melanoma and basal cell carcinoma

For the determination of cellular immunity status, mitogen-induced lymphocyte proliferation tests are used, along with measurements of cytokine secretion. The authors have established a test system with whole blood cell cultures in which they measured the following cytokines: alpha-interleukin-1 (alpha-IL-1), interleukin-2 (IL-2), gamma-interferon (tau-IFN), and alpha-tumor necrosis factor (alpha-TNF) in the supernatants by enzymoimmunologic methods. With this system, the authors tested blood samples of 72 patients with malignant melanoma, 38 patients with basal cell carcinoma, and 315 healthy control subjects. In the blood cell cultures of the patients with melanoma, significantly lower values of the lymphokines tau-IFN and IL-2 were found, compared with those of the control subjects, and the levels of the monokines alpha-IL-1 and alpha-TNF were reduced. tau-IFN values correlated with different clinical stages. In contrast, the patients with basal cell carcinoma had equal values for all four cytokines as an age-matched control group.

Evidence that treatment with vaccinia melanoma cell lysates (VMCL) may improve survival of patients with stage II melanoma. Treatment of stage II melanoma with viral lysates

A total of 80 patients with melanoma metastases in regional lymph nodes were treated by i.d. injections with a vaccine prepared from a vaccinia virus-infected allogeneic melanoma cell line; 39 patients have been followed for a 2-year period. Interim results from comparison of the treated group with 151 historical controls treated without the vaccine from September 1978 to December 1981 at the same institution and 56 non-randomized concurrent controls suggest that survival was significantly prolonged in the vaccinated group. At the 2-year period overall survival was 75% in the treated compared to 57% in the historical control group. Subset analysis showed a greater apparent benefit of vaccine therapy among patients who had metastases detected at the time of treatment of the primary melanoma (synchronous metastases), while therapy appeared less effective in patients with metastases detected at some time after treatment of the primary (delayed metastases). In the latter only those with one lymph node appeared to benefit from the treatment whereas in patients with synchronous metastases patients with three or more nodes as well as one node appeared to have improved survival. The survival rates at 2 years for treated patients with synchronous metastases in one, two, three or more lymph nodes was 100%, 83% and 79% respectively compared with that of 82%, 86% and 47% respectively in the equivalent control groups. Survival rates in treated patients with delayed metastases in one, two, three or more lymph nodes was 70%, 70% and 65% compared with 47%, 42% and 35% in the equivalent control groups. Treatment and control groups appeared well matched for a number of known prognostic features, including number and size of involved nodes, sex and thickness of primary tumor. Multivariate analysis indicated the effect of treatment was independent of these factors. Despite the empiricism of this approach the present results suggest that this form of therapy warrants further evaluation in a randomized controlled trial.

Current status and future prospects for adjuvant therapy of melanoma

Advances in the treatment of melanoma have resulted mainly from improved surgical management of the primary tumour assisted by a greater appreciation of major prognostic factors in the natural history of the disease. Further improvement in the treatment of melanoma will depend largely on introduction of methods to prevent recurrence of the disease. The present review discusses criteria for selection of patients with a high risk of recurrent disease and the adjuvant treatment that has been used in past studies to prevent recurrences. With few exceptions various regimens of chemotherapy, non-specific immunotherapy with bacterial products or combinations of these treatments have not increased disease free or survival periods. Immunotherapy with various sources of melanoma antigens or with viral lysates of melanoma cells have produced encouraging results in uncontrolled studies and require further evaluation. Several advances appear to provide scope for new initiatives in immunotherapy. These include an appreciation of the role of suppressor cells in regulation of immune responses against tumour cells and possible methods to inhibit their activity. A second is the definition of various lymphokines involved in generation of immune responses (particularly interleukin 2) and development of in vitro methods for large scale production of these factors. Thirdly, methods are becoming available to define the heterogeneity of tumour cells in terms of cell surface antigens or their release of soluble factors which may help select treatments appropriate to each patient.